Man who died had no fluids for six hours

A Clondalkin man died in Tallaght hospital after being left without intravenous fluids for six hours, his inquest has heard.

Peter Acton (61) died in the hospital in October 2005, two days after being admitted with pneumonia. The hospital has admitted negligence in ongoing legal proceedings by the family.

“He was lying on a hospital bed for hours and hours for want of a drink and nothing was done about it,” John Brennan, for the family, told Dublin Coroner’s Court. His clients were deeply suspicious of the hospital after being “stonewalled for 7½ years”.

Family members told the inquest how a cannula providing intravenous fluids came out of his arm but was not replaced for hours despite their repeated appeals to staff to do so.

Consultant gastroenterologist Dr Barbara Ryan said it was “critical” that Mr Acton had not been supplied with fluids at the very time when he needed them. She expressed her shock at his death, which occurred after her shift ended on October 2nd, 2005.

She acknowledged that it was very difficult to tell from the medical records how much fluid Mr Acton, who was suffering from dehydration, had received that day. It was clear a number of delays which occurred in his treatment had had an effect on the outcome.

Death certificate

Asked by Dublin city coroner Dr Brian Farrell why the death had not been referred to his office, Dr Ryan said she did not know. She agreed that Mr Acton’s death certificate was incorrectly issued as it referred wrongly to cancer as a cause of death.

She told the court the death triggered a review in the hospital of the way it monitored patients. An early warning score system had since been put in place. Nurses had also been trained in the placement of cannulas so there was no longer any need for them to wait for interns to do this.

On October 1st, 2005, Mr Acton was admitted to the hospital by ambulance. He was diagnosed with pneumonia. He was placed on a fluid drip and kept “nil by mouth”.

Lydia Acton said at one point her husband reached up and tried to squeeze the bag holding the fluids. They were allowed to wet his lips with moist swabs.

By the following day, his condition had deteriorated and sepsis had developed. Ms Acton said her husband told her his arm was sore because of the cannula in it delivering the fluids.

The nurse removed it and said a doctor would be along to fit a new one shortly.

“I kept calling the nurse and saying ‘when is this going to be put back in?’ but it wasn’t.” This went on “most of the day”.

“Peter said ‘take me home, I don’t want to die here’, but I said ‘don’t be silly, you’re not going to die’.”

Her husband became more agitated as time passed and said he thought he was dying. She found that his feet were freezing and alerted another nurse.

Intensive care

At this point, she said, there was a “rush” of doctors and nurses to her husband’s bedside and he was later brought to intensive care. Mr Acton died at 9.45am the following day.

Mr Acton’s son-in-law John Burke said that after his death, Dr Ryan told them she did not expect this outcome at the time she had gone home for the weekend. Mr Burke said Dr Ryan acknowledged to the family there had been a “catastrophic cascade of errors” in his treatment.

The inquest was adjourned to March, when other staff involved in the treatment of Mr Acton will be called. Lawyers for the hospital warned that it was not possible to identify some of these, while others were no longer at the hospital.